Dizziness is a common complaint in the chiropractic clinic. It is a generic term that must be clearly defined and its cause properly characterized and diagnosed for appropriate treatment to be implemented.
It is a complaint that is often treatable via chiropractic manipulative and myofascial (soft tissue) and rehabilitative procedures (like specific exercises and rehab).
The step in handling a dizziness complaint is to accurately identify the actual nature of the symptom. There are essentially four symptoms that can be described by a patient as being “dizziness.”
- Lightheadedness — The patient feels “not right in the head.”
- Presyncope — The patient feels “faint”
- Disequilibrium — The patient feels off balance, often as if they are being “pulled to one side” and feels as if they could easily fall over.
- Vertigo — The patient feels as if they are spinning or the world is spinning around them. This can often occur in acute attacks, or it can be a constant, low level feeling.
“It is important to stress that a cervical factor [misaligned vertebrae in the neck] may be present in all forms of vertigo and dizziness … in no field is manipulation [spinal adjustments] more effective than in the treatment of disturbances of equilibrium.” Karel Lewit, MD1
Michel Norre, a noted authority in the field of vertigo and disequilibrium, states: “The dysfunction causing vertigo concerns the total balance function and not the inner ear function alone.”2 The types of dizziness that are generally most likely to fall into the chiropractic rehabilitative realm are disequilibrium and vertigo.
Disequilibrium is most often cervical [misaligned vertebrae in the neck] in origin, as has been demonstrated by Hulse.3 It has been shown in several studies that the cervical spine [neck] plays a very strong role in the body’s regulation of equilibrium sense.4-7 In fact, Guyton7 states that the cervical spine [neck] plays the most important role in this regulation. One test that can be useful in determining whether a complaint of disequilibrium is of cervical origin is Hautant’s test.1
Vertigo, as stated earlier, is by definition an abnormal sensation of movement, usually spinning. Attacks of vertigo can be brought on by various maneuvers or can be constant. When the vertigo is caused by Meniere’s disease it is accompanied by unilateral tinnitus [ringing in the ear] and hearing loss. Benign positional vertigo is caused by dysfunction of the labyrinthine apparatus in the inner ear and attacks are brought on by changes of head position and can be tested for utilizing the Barany maneuver. Cervicogenic [neck related] vertigo also occurs in attacks and these attacks are brought on by changes in head position relative to the trunk. This can be tested for by utilizing the rotating stool test.8
Vetebrobasilar insufficiency can cause vertigo, though with this disorder the vertigo almost never occurs by itself,9 rather being generally accompanied by other symptoms of brainstem ischemia [poor blood supply], such as numbness in the ipsilateral [same sided] face and/or contralateral [other side] body; nausea; vomiting; loss of consciousness; visual problems; difficulty walking; incoordination of the extremities; tinnitus; speech problems and nystagmus [twitching of eye(s)]. These symptoms can be sometimes be provoked by rotation of the cervical spine and there may be a history of TIA [transient ischemic attack]. Vertigo caused by other brainstem diseases such as CP angle tumor can cause a constant, low intensity vertiginous sensation that increases in intensity as the tumor grows.
So it can be seen that before a referral or management strategy can be formulated, there must be accurate diagnosis of the cause of the disequilibrium or vertigo. There are various treatment/rehabilitative approaches that can be taken to restore normal function and eliminate the complaint.
When vertigo or disequilibrium is caused by dysfunction in the cervical spine or labyrinythine apparatus [inner ear], it is most often treatable in the chiropractic setting. Optimum function of the cervical spine is essential to the recovery from these disorders regardless of the cause. Lewit10 showed that patients with Meneire’s syndrome can be effectively treated with manipulation, demonstrating that 79 percent of 21 cases showed an “excellent” outcome. Fitz-Ritson8 showed that patients with post-traumatic vertigo of cervical origin treated with chiropractic manipulative, myofascial and rehabilitative procedures experienced a 90.2 percent success rate. Treatment must not only be directed towards the correction of joint dysfunction via manipulation [spinal adjustments], but must also be directed toward muscular dysfunction, such as myofascial trigger points and muscle tightness.11 In addition, faulty movement patterns of the cervical spine also including breathing and swallowing12 must be detected and corrected. This is especially important because often these patients will have imbalance in activity between the deep neck flexor muscles and the upper cervical extensor muscles. Checking for this imbalance and correcting it through rehabilitative procedures will help the patient improve locomotor system function as a whole and prevent treatment resistance and recurrence of the problem.
Patients with disorders of equilibrium often require additional training for complete restoration of equilibrial reaction to bring about normalcy. One of the most effective methods of doing this is through propriosensory retraining, a system of exercises that utilizes balance boards, balance beams, rocker boards, wobble boards and balance shoes. It creates a graded challenge to the patients equilibrial system to retrain their entire locomotor system to respond more appropriately (ultimately at optimum) to the gravitational perterbations with which we all are faced on a daily basis. The propriosensory exercises that are given to the patient are designed to reprogram the subcortical postural reactions that often become lost due to the sedentary lifestyle that many of us lead, as well as the locomotor system dysfunction that is often the underlying cause of vertigo and disequelibrium syndromes. As with other disorders of the locomotor system, one must look at the entire system, for the underlying cause of the clinical syndrome. This “holistic” approach will allow full assessment of the patient from a functional standpoint.
As with other locomotor system syndromes, reliable and valid outcome measures are an essential aspect of the appropriate management of the patient with dizziness. Demonstrating disability and treatment effectiveness is perhaps more important with this group of disorders than with many others because of the subjective nature of the clinical symptoms. One very effective means of documenting outcome is with the dizziness handicap inventory.13,14 This is a brief instrument that allows the treating doctor to demonstrate the degree to which the patient is disabled by their dizziness, and the impact the treatment and rehabilitation is having on this disability.
The various symptoms that fall under the category of dizziness can affect people in a variety of ways, from being a mild nuisance to being severely disabling. Appropriate intervention and treatment can often be essential to restoring normal daily activities of the patient.
- Lewit K. Manipulative Therapy in the Rehabilitation of the Motor System. Boston: Butterworths, 1985.
- Norre ME. Neurophysiology of vertigo with special reference to cervical vertigo: A review. Medica Physica 1986; 9:183-194.
- Hulse M. Disequilibrium, caused by a functional disturbance of the upper cervical spine. Clinical aspects and differential diagnosis. Man Med 1983; 1:18-23.
- de Jong PTVM, et al. Ataxia and nystagmus induced by injection of local anesthetics in the neck. Ann Neurol 1977; 1:240-246.
- Abrahams VC, Falchetto S. Hind leg ataxia of cervical origin and cervico-lumbar spinal interactions with a supratentorial pathway. J Physiol 1969; 203:435-447.
- Fitz-Ritson D. Neuroanatomy and neurophysiology of the upper cervical spine. In: Vernon H. ed. The Upper Cervical Syndrome: Chiropractic Diagnosis and Treatment. Baltimore: Williams and Wilkens, 1988:48-85.
- Guyton AC. Textbook of Medical Physiology. 7th ed. Philadelphia: Lea and Febiger, 1989.
- Fitz-Ritson D. Assessment of cervicogenic vertigo. J Manipulative Physiol Ther 1991; 14(3):193-198.
- Weiner HL, Levitt LP. Neurology for the House Officer. 4th ed. Baltimore: Williams and Wilkens, 1989.
- Lewit K. Disturbed balance due to lesions of the cranio-cervical junction. J Orthop Med 1998; 3:58-61.
- Murphy DR. The neglected muscular system: Its role in the pathogenesis of the subluxation complex. J Chiro 1990; 27(12):36-40.
- Murphy DR. The sternocleidomastoid muscle: Clinical considerations in the causation of head and face pain. Chiro Tech 1995; 7(1):12-17.
- Jacobson GP, Newman CW. The development of the dizziness handicap inventory. Arch Otolaryngol Head Neck Surg 1990; 116:424-427.
- Jacobson GP, Newman CW, Hunter L, Blzer BK. Balance function test correlates of the dizziness handicap inventory. J Am Acad Audiol 1991; 2:253-260.